Please fill out the following:

How has your life been affected because of the weight or lack of physical fitness? Your marriage, not dating, your family life, your career, etc. *

How has your energy level been? How has it affected your life? *

Have you been unhappy or even depressed about this? Why? *

Has your self-esteem been affected? In what way? How has it affected your life? *

What frustrates you the most about your excess body fat? *

How long have you been struggling with the weight you are? How many years? *

What was the defining moment or thing that happened that made you actually look into this program? Was it a picture you saw of yourself, someone said something, you tried on a certain pair of pants and they didn’t fit? What was it that made you actually get online and look into this? *

Why are you FINALLY fed up with this and ready to take action and make it better? *

Why now and not 6 months ago? What has changed in your life or within you that makes you want to do something about it NOW? *

What are your very specific goals? Not just “I want to lose a certain amount of weight” but WHY do you want to lose it? What will losing the weight do for you? *

What parts of your body do you want to see change? *

How will your life be different or improved when you get these results? *

What size pants or dress are going to get into with your Fit & Healthy Body? (this is individual for everyone, your Fit & Healthy Body size may be a 10 and you will be happier than ever). *